June 11, 2007

Treating Schizophrenia During Pregnancy

Pregnancy is a period of increased risk and vulnerability for women with schizophrenia and their future child.

An article in the May issue of "Clinical Psychiatry News" reported that when contrasted with women who don't have a mental illness, women who have schizophrenia have more unwanted sex and pregnancies, much poorer prenatal care, are at a increased likelihood of being a victim of violence during pregnancy, and a reduced likelihood of having a partner or husband. These are significant disadvantages that compound the risks for mother and child in addition to the direct impact of schizophrenia.

Following is a short excerpt from an interview with Dr. Laura Miller about inpatient work with women who have schizophrenia and are pregnant. Dr. Miller is a leader in women's mental health and manages a perinatal Mental Health Project at the University of Illinois at Chicago.

CPN: What are the key risks of pregnancy and the postpartum period in women with schizophrenia?

Dr. Miller: During pregnancy, key risks include delayed recognition of pregnancy, less prenatal care, failure to recognize labor, and a greater incidence of obstetric complications. A particularly high-risk symptom is psychotic denial of pregnancy, a condition in which the woman denies that she is pregnant despite clear indications, and thereby refuses prenatal care, misinterprets signs of labor, risks precipitous and unassisted delivery, and fails to bond with the baby.

The postpartum period is a time of increased risk for exacerbation of schizophrenia. Symptoms of schizophrenia can also adversely affect parenting capability, which leads to high rates of custody loss. At times, delusions and/or hallucinations about the baby directly interfere with bonding and parenting.

Negative symptoms of schizophrenia, such as apathy or difficulty expressing emotions, may contribute to under stimulation or neglect of a baby. The additional risks of obstetric complications and parenting difficulties for offspring who may be genetically vulnerable further heightens the long-term risk of psychiatric problems in the children of women with schizophrenia.

In the story Dr. Miller notes that key things for doctors to do is to do a thorough assessment of the mental and physical health of the woman. After doing the assessment the optimal treatment solution includes medication and psychoeducation to educate the woman (and ideally her partner) about understand the normal bodily changes accompanying pregnancy. The goal is to minimize the delusional misinterpretation of these changes and help the mother recognize signs related to pregnancy complications and labor.

Specific efforts can also be made to reduce the risk factors that impact her child (see Preventing Schizophrenia). For example, there is a high prevalence of smoking during pregnancy in women with schizophrenia - and smoking is well-known to harm the fetus in many different ways, lowering IQ and increasing risk of many physical and mental disorders. An intervention to help the mother stop smoking can reduce these risks to mother and child's health. The doctor (and family members and/or husband of the woman who is pregnant) might also help with making extra sure the woman gets the proper nutrition (fruits and vegetables, and key vitamins like Folic Acid, Omega fatty acids, Vitamin D, Choline, etc). Clinicians can also make an effort to identify the woman's parenting strengths and weaknesses, as well as the specific effects of symptoms on parenting attitudes and behaviors. Research has shown that the parenting skills that a parent has can have a significant impact on the longterm health (physical and mental) of the child.

Comments

Some women with the schizophrenia or schizoaffective diagnosis are doing very well out in society. They are married, go to college, have jobs, friends, and they and their spouse want to be parents.

There is a lack of information about the risks of many of the medications on fetal development, and brain outcome.

Some of the medications used are the same as those used by women with epilepsy, and more is known about those medications - such as Depakote being extremely dangerous but other antiseizure medications carrying less risk.

What these women with the diagnosis of "schizophrenia" or "schizoaffective disorder" that are doing very well and want to some day get pregnant and help raise children, need to know is -- which neuroleptic (antipsychotic) and antidepressant medications carry less risk? How much risk?

They need to be able to make better-informed decisions based on scientific data.

With better psychotropic medications and the availability of hormonal and nutritional augmentations, more women with these diagnoses are functioning in life like women without these diagnoses.

Doctors need to recognize that not all fit the stereotype of women with severe cases or untreated cases having unwanted pregnancies, etc.

For all the mentally healthy women "survivors" with these diagnoses and on these medications, who wish to make informed, rational decisions, they need better data.

I can only urge the medical and scientific communities that more studies be written up from data collected from all the numerous pregnancies that have already happened while women are on these various medications.

Families, and future, ~wanted~ children in loving homes are depending on them.